'What does good look like'-exploring access to healthcare for the homeless population in Gateshead, England.

BACKGROUND: individuals who are homeless encounter extreme health inequalities and as a result often suffer poor health. This study aims to explore ways in which access to healthcare could be improved for individuals who are homeless in Gateshead, UK. METHODS: twelve semi-structured interviews were conducted with people working with the homeless community in a non-clinical setting. Transcripts were analysed using thematic analysis. RESULTS: six themes were identified under the broad category of 'what does good look like', in terms of improving access to healthcare. These were: facilitating GP registration; training to reduce stigma and to provide more holistic care; joined-up working in which existing services communicate rather than work in isolation; utilising the voluntary sector as support workers could actively support access to healthcare and provide advocacy; specialised roles such as specialised clinicians, mental health workers or link workers; and specialised bespoke services for the homeless community. CONCLUSIONS: the study revealed issues locally for the homeless community accessing healthcare. Many of the proposed actions to facilitate access to healthcare involved building upon good practice and enhancing existing services. The feasibility and cost-effectiveness of interventions suggested requires further assessment.

Assessing the value for money of an integrated health and wellbeing service in the UK.

Lay health workers have been utilized to deliver health promotion programmes in a variety of settings. However, few studies have sought to determine whether these programmes represent value for money, particularly in a UK context. The present study involved an economic evaluation of Wellbeing for Life, an integrated health and wellbeing service in northern England. The service combined one-to-one interventions delivered by lay health workers (known as health trainers), group wellbeing interventions, volunteering opportunities and other community development activities. Value for money was assessed using an established economic model developed with input from a panel of commissioners and providers, and the main data source was the national health trainer data collection and reporting system. Between June 2015 and January 2017, behaviour change outcomes (i.e. whether client goals in relation to diet, physical activity, smoking or other behaviours, had been achieved) were recorded for 2433 of the 3179 individuals who accessed one-to-one interventions. The level of achievement observed gave an estimated total health gain of 287.7 quality-adjusted life years (QALYs). In addition, there were 4669 health-promoting events, five asset mapping projects and 1595 occurrences of signposting to other services. Combining the value of individual behaviour change with the value of these additional activities gave an overall net cost per QALY gained of £3900 and a total estimated societal value of at least £3.45 for every £1 spent on the service. These results suggest that the Wellbeing for Life service offered good value for money. Further research is needed to systematically and comprehensively determine the societal value of similar holistic, asset-based and lay-led approaches.

Effects of local authority expenditure on childhood obesity.

BACKGROUND: Under the 2013 reforms introduced by the Health and Social Care Act (2012), public health responsibilities in England were transferred from the National Health Service to local authorities (LAs). Ring-fenced grants were introduced to support the new responsibilities. The aim of our study was to test whether the level of expenditure in 2013/14 affected the prevalence of childhood obesity in 2016/17. METHODS: We used National Child Measurement Programme definitions of childhood obesity and datasets. We used LA revenue returns data to derive three measures of per capita expenditure: childhood obesity (<19); physical activity (<19) and the Children's 5-19 Public Health Programme. We ran separate negative binomial models for two age groups of children (4-5 year olds; 10-11 year olds) and conducted sensitivity analyses. RESULTS: With few exceptions, the level of spend in 2013/14 was not significantly associated with the level of childhood obesity in 2016/17. We identified some positive associations between spend on physical activity and the Children's Public Health Programme at baseline (2013/14) and the level of childhood obesity in children aged 4-5 in 2016/17, but the effect was not evident in children aged 10-11. In both age groups, LA levels of childhood obesity in 2016/17 were significantly and positively associated with obesity levels in 2013/14. As these four cohorts comprise entirely different pupils, this underlines the importance of local drivers of childhood obesity. CONCLUSIONS: Higher levels of local expenditure are unlikely to be effective in reducing childhood obesity in the short term.

Local authority commissioning of NHS Health Checks: A regression analysis of the first three years.

In April 2013, the public health function was transferred from the NHS to local government, making local authorities (LAs) responsible for commissioning the NHS Health Check programme. The programme aims to reduce preventable mortality and morbidity in people aged 40-74. The national five-year ambition is to invite all eligible individuals and to achieve an uptake of 75%. This study evaluates the effects of LA expenditure on the programme's invitation rates (the proportion of the eligible population invited to a health check), coverage rates (the proportion of the eligible population who received a health check) and uptake rates (attendance by those who received a formal invitation letter) in the first three years of the reforms. We ran negative binomial panel models and controlled for a range of confounders. Over 2013/14-2015/16, the invitation rate, coverage rate and uptake rate averaged 57% 28% and 49% respectively. Higher per capita spend on the programme was associated with increases in both the invitation rate and coverage rate, but had no effect on the uptake rate. When we controlled for the LA invitation rate, the association between spend and coverage rate was smaller but remained statistically significant. This suggests that alternatives to formal invitation, such as opportunistic approaches in work places or sports centres, may be effective in influencing attendance.

Directors of public health as 'a protected species': qualitative study of the changing role of public health professionals in England following the 2013 reforms.

Background: The Health and Social Care Act 2012 gave councils in England responsibility for improving the health of their populations. Public health teams were transferred from the National Health Service (NHS), accompanied by a ring-fenced public health grant. This study examines the changing role of these teams within local government. Methods: In-depth case study research was conducted within 10 heterogeneous councils. Initial interviews (n = 90) were carried out between October 2015 and March 2016, with follow-up interviews (n = 21) 12 months later. Interviewees included elected members, directors of public health (DsPH) and other local authority officers, plus representatives from NHS commissioners, the voluntary sector and Healthwatch. Results: Councils welcomed the contribution of public health professionals, but this was balanced against competing demands for financial resources and democratic leverage. DsPH-seen by some as a 'protected species'-were relying increasingly on negotiating and networking skills to fulfil their role. Both the development of the existing specialist public health workforce and recruitment to, and development of, the future workforce were uncertain. This poses both threats and opportunities. Conclusions: Currently the need for staff to retain specialist skills and maintain UKPH registration is respected. However, action is needed to address how future public health professionals operating within local government will be recruited and developed.

Designing equitable workplace dietary interventions: perceptions of intervention deliverers.

BACKGROUND: Workplaces are a good setting for interventions that aim to support workers in achieving a healthier diet and body weight. However, little is known about the factors that impact on the feasibility and implementation of these interventions, and how these might vary by type of workplace and type of worker. The aim of this study was to explore the views of those involved in commissioning and delivering the Better Health at Work Award, an established and evidence-based workplace health improvement programme. METHODS: One-to-one semi-structured interviews were conducted with 11 individuals in North East England who had some level of responsibility for delivering workplace dietary interventions. Interviews were transcribed verbatim and analysed using thematic framework analysis. RESULTS: A number of factors were felt to promote the feasibility and implementation of interventions. These included interventions that were cost-neutral (to employee and employer), unstructured, involved colleagues for support, took place at lunchtimes, and were well-advertised and communicated via a variety of media. Offering incentives, not necessarily monetary, was perceived to increase recruitment rates. Factors that militate against feasibility and implementation of interventions included worksites that were large in size and remote, working patterns including shifts and working outside of normal working hours that were not conducive to workers being able to access intervention sessions, workplaces without appropriate provision for healthy food on site, and a lack of support from management. CONCLUSIONS: Intervention deliverers perceived that workplace dietary interventions should be equally and easily accessible (in terms of cost and timing of sessions) for all staff, regardless of their job role. Additional effort should be taken to ensure those staff working outside normal working hours, and those working off-site, can easily engage with any intervention, to avoid the risk of intervention-generated inequalities (IGIs).

Impact and acceptability of lay health trainer-led lifestyle interventions delivered in primary care: a mixed method study.

Aim To evaluate the impact and acceptability of offering one-to-one lifestyle interventions delivered by lay health trainers in the primary care setting. BACKGROUND: Chronic conditions represent major causes of ill-health, avoidable disability, pain and anxiety, and tend to be more prevalent in less affluent groups. This is due, in part, to the link between unhealthy lifestyles and lower socio-economic status, although factors such as poverty, worklessness and social exclusion play a larger role. Lay health trainers were introduced in England with the aim of providing personalised lifestyle advice, support and access to services for people living in disadvantaged areas. There is a body of literature on the effectiveness of lay or community health workers in the management of chronic conditions. However, little is known about their potential to promote lifestyle changes in newly diagnosed patients. An innovative health trainer service was piloted in the primary care setting, to work with people diagnosed with a chronic condition or identified as potentially benefitting from one-to-one support. METHODS: A mixed method study design was utilised. Semi-structured interviews and focus groups were conducted with practice staff (n=11) and patients (n=15) from one primary care practice in North East England, United Kingdom. Discussions were audio-recorded and analysed using a thematic content approach. Routinely collected pre-/post-intervention data (n=246 patients at baseline; sample sizes varied at end line) were analysed and appropriate descriptive and summary statistics produced. Findings The discussions highlighted a high level of satisfaction with the health trainer model in terms of supporting positive lifestyle changes. Locating the intervention within the practice removed access barriers, particularly for those with long-term conditions. Anecdotal evidence of health improvement was supported by the quantitative analyses, which revealed statistically significant improvements in body mass index, blood pressure, dietary habits, exercise levels, alcohol intake, self-rated health and self-efficacy amongst those who completed the intervention.

Making and maintaining lifestyle changes with the support of a lay health advisor: longitudinal qualitative study of health trainer services in northern England.

OBJECTIVE: To explore and document the experiences of those receiving support from a lay health trainer, in order to inform the optimisation and evaluation of such interventions. DESIGN: Longitudinal qualitative study with up to four serial interviews conducted over 12 months. Interviews were transcribed and analysed using the constant comparative approach associated with grounded theory. PARTICIPANTS: 13 health trainers, 5 managers and 26 clients. SETTING: Three health trainer services targeting disadvantaged communities in northern England. RESULTS: The final dataset comprised 116 interviews (88 with clients and 28 with staff). Discussions with health trainers and managers revealed a high degree of heterogeneity between the local services in terms of their primary aims and activities. However, these were found to converge over time. There was agreement that health trainer interventions are generally 'person-centred' in terms of being tailored to the needs of individual clients. This led to a range of self-reported outcomes, including behaviour changes, physical health improvements and increased social activity. Factors impacting on the maintenance of lifestyle changes included the cost and timing of health-promoting activities, ill-health or low mood. Participants perceived a need for ongoing access to low cost facilities to ensure that any lifestyle changes can be maintained in the longer term. CONCLUSIONS: Health trainers may be successful in terms of supporting people from socio-economically disadvantaged communities to make positive lifestyle changes, as well as achieving other health-related outcomes. This is not a 'one-size-fits-all' approach; commissioners and providers should select the intervention models that best meet the needs of their local populations. By delivering holistic interventions that address multiple lifestyle risks and incorporate relapse prevention strategies, health trainers could potentially have a significant impact on health inequalities. However, rigorous, formal outcome and economic evaluation of the range of health trainer delivery models is needed.

Cost-effectiveness of health-related lifestyle advice delivered by peer or lay advisors: synthesis of evidence from a systematic review.

BACKGROUND: Development of new peer or lay health-related lifestyle advisor (HRLA) roles is one response to the need to enhance public engagement in, and improve cost-effectiveness of, health improvement interventions. This article synthesises evidence on the cost-effectiveness of HRLA interventions aimed at adults in developed countries, derived from the first systematic review of the effectiveness, cost-effectiveness, equity and acceptability of different types of HRLA role. METHODS: The best available evidence on the cost-effectiveness of HRLA interventions was obtained using systematic searches of 20 electronic databases and key journals, as well as searches of the grey literature and the internet. Interventions were classified according to the primary health behaviour targeted and intervention costs were estimated where necessary. Lifetime health gains were estimated (in quality-adjusted life years, where possible), based on evidence of effectiveness of HRLAs in combination with published estimates of the lifetime health gains resulting from lifestyle changes, and assumptions over relapse. Incremental cost-effectiveness ratios are reported. RESULTS: Evidence of the cost-effectiveness of HRLAs was identified from 24 trials included in the systematic review. The interventions were grouped into eight areas. We found little evidence of effectiveness of HRLAs for promotion of exercise/improved diets. Where HRLAs were effective cost-effectiveness varied considerably: Incremental Cost effectiveness Ratios were estimated at £6,000 for smoking cessation; £14,000 for a telephone based type 2 diabetes management; and £250,000 or greater for promotion of mammography attendance and for HIV prevention amongst drug users. We lacked sufficient evidence to estimate ICERs for breastfeeding promotion and mental health promotion, or to assess the impact of HRLAs on health inequalities. CONCLUSIONS: Overall, there is limited evidence suggesting that HRLAs are cost-effective in terms of changing health-related knowledge, behaviours or health outcomes. The evidence that does exist indicates that HRLAs are only cost-effective when they target behaviours likely to have a large impact on overall health-related quality of life. Further development of HRLA interventions needs to target specific population health needs where potential exists for significant improvement, and include rigorous evaluation to ensure that HRLAs provide sufficient value for money.